A new global industry has sprung up, as have many before, what can we learn?


Perhaps you may think that I am talking about medical tourism….

But, although the parallels are scarily similar, the real subject of the above paragraph is the rise of the direct insurance market in the 1970s and 1980s. By direct insurance, I mean the innovation of phone-based insurance using call centres that replaced a paper, postal and personal visit basis.

I was sitting in the garden recently having a break from the screen, and the fleeting thought that with medical tourism I had been here before. Medical tourism demonstrates almost all the same elements as the rise of the phone based motor and home insurance market.

The good news is that if the parallels are correct, then medical tourism will cease to become an innovation and become a permanent part of the healthcare industry. The even better news is that if the parallels continue, those seeking to make a fast buck in the growth stages will move on to the next new opportunity with another batch of willing victims.

How the direct by-phone market developed has valuable lessons for medical tourism, as very few of the industry players who thought it the answer to their prayers survived the journey.

Where predictions of the direct insurance market went wrong

There were two main predictions. One was that by 2000, 95% of the market would buy over the phone. The other was that by 2010, 90% of the European, if not global personal lines insurance market would be controlled by bank owned insurers. Banks have been running away from insurance and selling insurers at knockdown prices. The rise of the internet and price comparison sites were two factors that meant the 95% projection was bypassed by new developments.  There is a lesson here for medical tourism when making over-bold predictions,.

A cross–border opportunity

One of the big projections for Europe was that insurers would be able to sell direct insurance from one country to all of Europe. Leading insurance companies set up subsidiaries to do this. Apart from a tiny amount around the edges of insurance, cross-border provision failed dismally. People will use technology but 99% will only buy from an insurer or intermediary based in their own country. Insurers lost huge sums on these ventures.

Now, by definition, medical tourism is cross-border so you may assume the same logic cannot apply. Some consultants are making money persuading countries and companies that people will fly half way across the world to take advantage of low cost healthcares. Today, I read a feature that correctly says that much of the demand for private healthcare in Asia comes from Africa and the Middle East. It then went on to argue that the future of medical tourism in Asia is to focus on the American and European market. But according to some experts, so should South and Central America, The Middle East and Europe. If medical tourism follows the insurance model, then most people will not travel large distances, they will travel more locally; within Europe, within the Americas and within Asia. If this is true, many destination marketing campaigns are doomed to failure.

The conference business

In the last twelve months, IMTJ included 52 (yes…. 52) national and international conferences and congresses in its Medical Travel Events Calendar that were directly related to medical travel and medical tourism.

As with medical tourism, the first few conferences related to the direct insurance market were mostly very informative, with people wanting to know about the potential as insurers or suppliers or intermediaries.

After the initial enthusiasm, conferences became very similar. The same organizers, speakers, topics and advertisers. Several consultants made a living just touring the word as conference speakers. It became a mini-industry and stopped caring if it helped anyone, caring only about how much it made the organizers and speakers. The direct insurance conference business is now defunct; those in the industry found other ways to exchange information.

The lesson for medical tourism is that conferences attracted four types of people:

  • Genuine seekers after knowledge who took the information and contacts back to their companies. These disappeared in later years as the originals either set up direct insurers or abandoned the project.
  • Existing competitors who wanted to know out about it to find ways of reducing the impact on their business.
  • Entrepreneurs wanting to set up new companies. Only a handful of these actually did that; some some made a little money and got out, while the rest lost a lot of money (rarely their own) on failed ventures.
  • Conference groupies who enjoy conferences as it kept them out of the office, travelled the world, made endless promises to contacts but ultimately wasted everyone’s time!

The role of the agent

The model of direct insurance was to completely cut out the middle-man….all those thousands of company agents and independent intermediaries. The gurus predicted that by 2000, independent insurance intermediaries for home and motor insurance would be as extinct as the dinosaur, with perhaps a few left to serve the better off. Although numbers have dwindled, they are far from extinct, surviving by harnessing the very technology built to destroy them. They found that some people want face-to-face advice and personal service.

Insurance intermediaries that survive and thrive know where their market is, offer good service at a fair price, and keep developing and learning. Medical tourism agents, who do the same thing, may prosper. Those who provide no added value, too few providers, and poor service will have to find other ways of making a living.

Price and price comparisons

The biggest lesson of all is on price. It was assumed that the cheapest insurer would get most of the business and wipe out competitors. But the customer found that what one company offered was not the same as another, so this did not happen. Also, competition was driven by added value and service…so companies that offered better service and better value often took business from competitors who were cheaper. Many companies who could not compete on price, service or cover did go out of business. The biggest UK direct insurer is now selling on service rather than price.

Some medical tourism gurus call for complex mechanisms where customers can tell at a glance the costs and extras of treatment in hundreds of hospitals across the world. Sounds ideal. But not for hospitals. Insurance did develop price comparison sites, which became so effective that they now, at least in the UK, dominate with 80% of the market. But the top two insurers found that their plans to sell on cover not price were confounded, and after withdrawing from price comparison sites have rebuilt income, profit and market share.

The lesson for medical tourism is that price is not the sole answer. Competing on price drives prices and quality ever lower.  And if you still think price is the only criteria, when you bought your last car did you buy the cheapest car, or one that suited your needs and your budget?

Insurance companies

Almost every home and motor insurer wanted to join in the direct insurance market, it seemed. But for every one that set up as a direct insurer, at least one decided not to. For every ten who set up a direct insurance company or unit, only one is still there, and few of them are owned by the same owners as then.

While insurers saw direct insurance as either their saviour or their doom, in medical tourism many see insurance companies as the next big opportunity. The direct insurance experience teaches us that insurers will investigate new ideas, but more to see how they can compete with, buy out, or kill them, rather than how they can join in. They will talk and pilot schemes, mostly to be able to say, “ we tried medical tourism and found it wanting”, and then use it as a stick to beat hospital prices down.


Direct insurers underestimated the competition. Many of those insurers are still around, while newer direct insurers have folded. Those insurers used the same technology as the direct insurance underwriters. In the UK, where direct writing began, how insurers fought back will not be found in any reports or press cuttings; monthly meetings of non-direct insurers exchanged data and prices and trends on home and motor insurance, software was developed for what if projects, mystery shopping was used to find out direct writer prices, and new research projects were developed by groups of insurers. On all these, direct writers were not invited. The fiercest competition often came from within an insurer where a direct arm was created; they worked against each other rather than together. The effect was that direct writers did not win the market share they expected.

The lesson for medical tourism is that existing health providers will not just lie down and let their best business be taken. How they will do it may differ by country. Also, as tourism is finding out, domestic holidays are replacing trips abroad due to a combination of cost, awareness of air miles and changes in habits; so competition can be as much consumer driven as provider driven.


Another comparison between direct insurance and medical tourism is lack of professionalism in an early stage market.  Many of those entering direct insurance as an insurer, or later as a telebroker, were not from insurance. Those who quickly became professional, and had relevant backgrounds in marketing and technology, made a success of it (at least until someone invented the internet!) Those who thought they could muddle along, and this includes insurers and banks that thought proper marketing and the latest technology were both unnecessary to success, failed miserably.

The lesson for medical tourism is that although new ideas are necessary, for even the remotest chance of long term survival, people and companies involved have to understand marketing, sales, technology and healthcare,

Not one thing or the other

Most of you will probably be confused as to which insurer is a direct writer and which is not. This is because the old model –  a company is either a direct insurer, or a non-direct insurer has gone. The internet has blasted away the divide and most insurers now use a mix of distribution channels

The lesson for medical tourism is that domestic health care or medical tourism may already be old-fashioned. Dental tourism is an example where checks and after-care can be carried out in the home country, and dental work abroad, with some providers already offering the option of treatment at home or overseas. With proper global healthcare, medical tourism will not be an afterthought but an integral part of patient health care.

Final thoughts

If the parallels are right, medical tourism will also move from being a short-term one-hit wonder…to a specialist niche market…to becoming a mainstream part of the global healthcare market. There will be many disappointments, but those in it who keep moving forward and are professional in what they do will prosper and survive.

Inevitably, when the predictions of huge medical tourism numbers fail to come to pass, the blame will be put on the media, the consumers and the employers for not understanding the offer, and on world events…not on those who made the predictions.

The biggest lesson the parallel can teach medical tourism is that always around the corner is a major development that can destroy all predictions and change the state of play totally!

I am off to the garden now to think what the next “new global idea “ will be…..


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